Comparative Effectiveness of Trimodal Therapy Versus Radical Cystectomy for Localized Muscle-invasive Urothelial Carcinoma of the Bladder.

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European urology


Given the lack of randomized evidence comparing trimodal therapy (TMT) to radical cystectomy (RC) for muscle-invasive urothelial carcinoma of the bladder (UCB), we performed an observational cohort study to examine the comparative effectiveness of these two definitive treatments. Within the National Cancer Data Base (2004-2011),we identified 1257 (9.8%) and 11 586 (90.2%) patients who received TMT and RC, respectively. Inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier analysis showed that median overall survival (OS) was similar between the TMT (40 mo, 95% confidence interval [CI] 34-46) and RC groups (43 mo 95% CI 41-45; p=0.3). In IPTW-adjusted Cox regression analysis with a time-varying covariate, TMT was associated with a significant adverse impact on long-term OS (hazard ratio 1.37, 95% CI 1.16-1.59; p<0.001). Interaction terms indicated that the adverse treatment effect of TMT versus RC decreased with age (p=0.004), while there was no significant interaction with gender (p=0.6), Charlson comorbidity index (p=0.09) or cT stage (p=0.8). In conclusion, we found that TMT was generally associated with worse long-term OS compared to RC for muscle-invasive UCB. However, the survival benefit of RC should be weighed against the risks of surgery, especially in older patients. These results are preliminary and emphasize the need for a randomized controlled trial to compare TMT versus RC.

PATIENT SUMMARY: We examined the comparative effectiveness of trimodal therapy versus radical cystectomy for muscle-invasive urothelial carcinoma of the bladder. We found that trimodal therapy was generally associated with worse long-term overall survival, although there may be no difference with radical cystectomy in older individuals.

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Aged; Aged, 80 and over; Chemoradiotherapy, Adjuvant; Comparative Effectiveness Research; Cystectomy; Female; Humans; Kaplan-Meier Estimate; Logistic Models; Male; Middle Aged; Multivariate Analysis; Muscle, Smooth; Neoadjuvant Therapy; Neoplasm Invasiveness; Neoplasm Staging; Proportional Hazards Models; Risk Factors; Time Factors; Treatment Outcome; Urinary Bladder Neoplasms; Urothelium

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